Provider Demographics
NPI:1013713163
Name:ROBERTSON, MACKENZIE JORDAN (MS, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:MACKENZIE
Middle Name:JORDAN
Last Name:ROBERTSON
Suffix:
Gender:
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1569 SW 45TH RD
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-9126
Mailing Address - Country:US
Mailing Address - Phone:304-617-2040
Mailing Address - Fax:
Practice Address - Street 1:1569 SW 45TH RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-9126
Practice Address - Country:US
Practice Address - Phone:304-617-2040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-20
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA129941235Z00000X
OR18429235Z00000X
FLSA21430235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist